This story is produced and presented by The University of Vermont Medical Center

Childhood experiences, both positive and negative, have a lifelong impact on our health and well-being. Consider this: People with positive childhood experiences live 20 more years on average than those with negative experiences. That’s quite an impact. And there’s more. The landmark Kaiser ACE Study — ACE stands for Adverse Childhood Experience —shows links between negative experiences and risky behavior, psychological issues, serious illness, and the leading causes of death.

Read or listen to an interview with Michelle Shepard, MD, PhD, pediatrician at the University of Vermont Children’s Hospital. She is also an assistant professor at the Larner College of Medicine at UVM, and she works with the Vermont Child Health Improvement Program.

What are adverse childhood experiences?

Shepard: ACEs refers to a group of 10 identified childhood experiences that can lead to long-term negative effects on emotional and physical health. ACEs include abuse, neglect, family hardships, and household mental illness and substance abuse.

What happens to a child’s mind and body when they have an adverse experience?

Shepard: What happens depends on the age of the child when they have the experience. Adversity experienced early in a child’s development (before 5-years-old) is particularly devastating because the child is still developing his or her stress response system. If the child experiences chronic exposure to stressful situations, they can develop elevated levels of stress hormones and then react more strongly to negative exposures in their environment.

Children that experience ACEs are more susceptible to issues with their physical health such as growth problems, obesity, autoimmune diseases, and diabetes. They also have a higher incidence of asthma and tend to get sick more often than children without ACEs.

ACEs early in childhood impacts a child’s learning and behavior. Children with even two adverse childhood experiences are significantly more likely to be diagnosed with a learning disability, or a behavioral problem such as ADHD. With most ACEs there is a graded relationship so more ACEs increases your chances of have emotional, behavioral or health problems.

What are the types of ACES?

Shepard: Ten ACEs were identified in the original study including forms of childhood abuse and household dysfunction.

Abuse (physical, emotional and/or sexual)

Neglect (physical and/or emotional)

Intimate partner violence (witnessing violence towards a parent)

Incarcerated parent

Parents who are divorced or separated

Substance abuse in the household

Mental illness in the household

There’s a graded dose response, so more ACEs lead to higher incidences of emotional and physical health problems. So, somebody who has zero ACEs has a much lower risk of chronic health problems in adulthood like diabetes, heart disease, stroke, heart attack, and autoimmune diseases than those that have 2 or more ACEs. If you have one ACE you have a slightly increased risk, but if you have four or more ACEs, your risk for some of these long-term health issues is much, much higher.

What is the science underlying the connection?

Shepard: Research from over the last 20 years shows that the many of the long-term effects of ACEs are through the involvement of the stress response system of the body. These hormones regulate not just stress, but also the immune system, the developing brain, and the way your emotions affect your ability to learn, to regulate yourself, and to respond to a scary situation.

All these developmental processes can be disrupted by ongoing traumatic experiences. ACEs turn on a stress response that evolved the protect us. So, the systems kicked in when we wanted to get away from predators, but we don’t want them to kick in to fight or flight when we’re at home with our family. The ongoing stress response activation can then turn different areas of the brain down or up. So, the area of the brain for executive functioning to override fight or flight can get turned down. The areas that control fear get turned up, and in turn people respond heavily to even small stressors.

Turning on the stress response can also impact other hormones in the body. Kids may have trouble with growth. A lot of children with ACEs deal with obesity, not because they want to eat that way, although that may be what’s available to them, but because their body craves high-calorie, high-fat foods due to the activated stress response. The stress response effect on the immune system means children with ACEs get ill more often. Being ill more often has a cascading effect: for example, they miss school, get behind, then feel overwhelmed and may lead to issues with behavior and lack of attention. Elevated stress hormones and the effects on the immune system may underlie the increased risks of health problems later in life.

How common are ACEs?

Shepard: National data is collected annually through the Behavioral Risk Factor Surveillance System. In the 32 states (including Vermont) that include ACE questions, 60 percent of those who were interviewed reported at least one ACE and 14% reported 4 or more ACEs. People who have four or more ACEs have significant effects on their health and have a shorter life expectancy. Here in Vermont, 1 in 8 people report multiple ACEs

Is there a screening for ACEs?

Shepard: Yes, there are multiple versions of the ACE questionnaire, however, in many practices it is not yet a routine screening tool used during wellness visits. However, routine screening for Social Determinants of Health including depression, intimate partner violence, housing, and food insecurity is currently being done in our practice and many practices throughout Vermont.

How do ACEs affect our lives?

Shepard: The original ACE study interviewed more than 17,000 adults with an average age of 59 years who were recalling events that happened to them before the age of 18. The findings were very striking in that the more of these adverse childhood experiences they reported, the more health impacts they had.

Having 2 or more ACEs increases your risk for heart attack, stroke, early heart disease, asthma, diabetes, and health conditions and the more ACEs you have the higher your risk. ACEs also impact mental health with higher rates of depression, suicide, and substance abuse. Having multiple ACEs also affects people in the social and economic realms. You are more likely to have a lower education level, to live in poverty, and to suffer from economic hardship. So ACEs affect not only your health, but other aspects of your life as well.

The CDC estimates the lifetime costs associated with child maltreatment at $124 billion. What is the societal impact?

Shepard: There are huge impacts on society including the costs of treatment for health-related complications, mental illnesses, and substance abuse in adults who experiences multiple ACEs. There is also lost productivity at work as people that have experienced ACEs are more likely to be disabled, and they miss more work days due to illness. It’s also a generational issue- such that if you have experienced multiple ACEs, your children are more likely to experience some of those same ACEs, then you’re missing work because your child is sick more often and they’re out of school as well. Unfortunately, it can continue as a pattern not only through life exposures and household challenges but actually through the genetics that can get changed early in life related to ACEs.

What do you mean about genetic changes?

Shepard: We all receive genes from both our parents. During a child’s development, the expression of these genes can be turned up, down or even off due to stressors or ACEs early in life. These changes in gene expression are known as epigenetics. If the expression of health favorable genes are turned down or off, or less favorable genes are turned on or up these can have lifelong effects on your risks of developing negative health outcomes. So the early life exposures of children can impact their gene expression and throughout their lifetime and increase their disease risk.

What can be done about ACEs?

Shepard: I think the biggest thing is to encourage people to talk about it, because if we don’t ask and you don’t tell us, we can’t help. Although I hope to see screening become more widespread, it’s important to come and talk about it. Your doctor’s office is a safe place to bring your concerns if you’re worried about abuse or neglect, that you may be depressed and it’s affecting your child, or your substance use is affecting your child. Come and ask for help.

Early intervention is key: the earlier you can get in and start working with a child, the more likely they are to develop a more adaptive response. There is significant brain development occurring in the first 5 years of life with millions of neurons in the brain maturing their connections. Removing or decreasing ACEs early in life may help protect children from developing these poor health outcomes as adults. By building resilience and fostering healthy relationships we can help these children succeed.

What does resilience look like in the face of ACEs?

Shepard: When we talk about resilience, we’re talking about adaptive responses to hardships of ACEs. Children need positive, safe relationships with adults. So, if a family member is absent due to divorce, due to incarceration, due to mental health issues, finding another stable caring adult and forming that relationship will really help with the child’s trust, with the ability to feel safe, and that can have profound effects on the ability to be resilient later on.

Providing good nutrition and daily exercise positively counters the impact of adverse childhood experiences. Having a child participate in something they feel they are good at, or are proud of turn on the “feel good” parts of the brain. Adults who experienced multiple ACEs may have a decreased ability to feel the effects of dopamine in the pleasure centers of the brain and may turn to substance use to feel better, which sets them up for addiction. We want to intervene as early as possible and encourage positive behaviors such as exercise that lead to dopamine release in children. Having a child involved in sports, a club or other group activities with other kids to get positive reinforcement and to feel good about themselves is important.

Dr. Michelle Shepard is a pediatrician at the University of Vermont Medical Center and assistant professor at the Larner College of Medicine at UVM. Dr. Shepard practices general pediatrics which includes well child visits, sick care and management of chronic illnesses. Her special interests include supporting breastfeeding and the care of children and families affected by addiction. In addition to her clinical work, Dr. Shepard works on multiple research and quality improvement projects through the Vermont Child Health Improvement Program.

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